<p> 1</p><p>6650 SW Capital Hwy Portland, OR 97219 PH: 503-246-1663 x7302/FX: 503-244-180 INTAKE APPLICATION This application DOES NOT GUARANTEE ENROLLMENT. You will be notified regarding the results of your application</p><p>ERSEA USE ONLY INTAKE STAFF ONLY</p><p>Date Received: ______Staff Initials: ______Start Date: ______New Student: ______Enrollment Approved by:______Returning Student: ______Program Director Preferred Center: ONLY 1. ______2. ______A.M. ______Today’s Date: ______P.M. ______Full Day: ______Today’s Date: ______</p><p>How did you hear about Neighborhood House: ______</p><p>CHILD INFORMATION</p><p>Child’s Name: ______DOB: ______</p><p>Gender: M F Applying for: EHS HS </p><p>Primary Language Spoken in the Home: ______</p><p>Race: Asian Black White American/Alaska Native Multi-Racial </p><p>Hawaiian/Pacific Islander Refused Unknown Other</p><p>Ethnicity: Latino/Hispanic Yes No</p><p>Has this child previously attended EHS, HS or PP Program: Yes No </p><p>If yes, which program: EHS HS PP Foster Child? Yes No</p><p>Disability or Health Impairment: Yes No </p><p>If yes, what type: ______</p><p>Early Intervention / Special Education Services: Yes No</p><p>Which of the following phrases describe your child’s behaviour: </p><p>Shy Outgoing High Energy Easy Going Gets Frustrated Easily Independent</p><p>Approved on: 4/27/2016 2</p><p>IE OI WL Date: ______Assigned to: ______</p><p>PARENT/GUARDIAN INFORMATION</p><p>Parent/Guardian Name: ______DOB: ______</p><p>Gender: M F Address: ______</p><p>Phone Number(s): ______, ______</p><p>Primary Language Spoken in the Home: ______</p><p>E-mail Address: ______</p><p>Race (circle ONE): Race: Asian Black White American/Alaska Native Multi-Racial </p><p>Hawaiian/Pacific Islander Refused Unknown Other</p><p>Ethnicity: Latino/Hispanic Yes No</p><p>Marital Status (circle ONE): Single Married Separated Divorced Widowed</p><p>Custody: Yes No Teen Parent: Yes No Highest Level of Education: ______</p><p>Employment Status: ______Attending School: Yes No</p><p>Parent/Guardian Name: ______DOB: ______</p><p>Gender: M F Address: ______</p><p>Phone Number(s): ______, ______</p><p>Primary Language Spoken in the Home: ______</p><p>E-mail Address: ______</p><p>Race (circle ONE): Race: Asian Black White American/Alaska Native Multi-Racial </p><p>Hawaiian/Pacific Islander Refused Unknown Other</p><p>Ethnicity: Latino/Hispanic Yes No</p><p>Marital Status (circle ONE): Single Married Separated Divorced Widowed</p><p>Custody: Yes No Teen Parent: Yes No Highest Level of Education: ______</p><p>Employment Status: ______Attending School: Yes No</p><p>HOUSEHOLD INFORMATION </p><p>Living Address: ______Phone numbers: ______</p><p>Mailing Address (if different): ______</p><p>Approved on: 4/27/2016 3</p><p>6650 SW Capital Hwy Portland, OR 97219 PH: 503-246-1663 x7302/FX: 503-244-180 INTAKE APPLICATION Parental Status (circle ONE): One parent Two parent Guardian(s)</p><p>Homeless Family: Yes No Foster Family: Yes No</p><p>Number of People in Household: ______Number of Family Members in Household: ______</p><p>FAMILY CIRCUMSTANCES EHS/HS ONLY</p><p>Disabled family Member Yes No Domestic Violence Yes No</p><p>Immigrant/Refugee Family Yes No Substance Abuse/ Recovery Yes No</p><p>Subsidized Housing Yes No DHS referral Yes No </p><p>Previous Foster Care: Yes No </p><p>Parent/Guardian Incarceration/Probation Yes No</p><p>Child Abuse or Neglect (prenatal exposure to drugs/Alcohol/Tobacco) Yes No</p><p>INCOME/ ELIGIBILITY INFORMATION</p><p>Current Annual Income (Approximately): ______</p><p>Current Monthly Income (Approximately): ______</p><p>DOES YOUR FAMILY RECEIVE ANY OF THE FOLLOWING? EHS/HS ONLY</p><p>TANF: Yes No SNAP: Yes No Supplemental Security Income: Yes No WIC: Yes No ERDC: Yes No OHP: Yes No</p><p>FAMILY EMERGENCY NEEDS</p><p>Food Yes No Clothing Yes No Health Care Yes No Housing Yes No </p><p>Utilities Yes No Child Support Yes No Protective Services Yes No Other:______Resources provided: ______</p><p>CERTIFICATION</p><p>I certify that this information is true. If any part is false, my participation in this agency’s program may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal hours.</p><p>Parent/Guardian Signature______Date______</p><p>Parent/Guardian Signature______Date______</p><p>Approved on: 4/27/2016 4</p><p>Approved on: 4/27/2016</p>